Effects of surgical approaches for acetabular fractures with associated gluteal vascular injury

Buttock claudication disclosing a thrombosis of the superior left gluteal artery: Report of a case diagnosed by a selective arteriography of the iliac artery, and cured by per-cutaneous stenting

We report on a case of left buttock claudication, occurring consistently after 150 meters walking, and disappearing after a short rest. As magnetic resonance angiography (MRA) did not show any explanation for this claudication, a selective angiography of left internal iliac artery was requested, which clearly identified a tight stenosis of the onset of the left superior gluteal artery. A per-cutaneous angioplasty together with stenting of this artery, induced a prompt and complete relief of pain at the three months follow-up visit.

Entrapment of the external iliac vein in a both-column acetabular fracture

We present a patient with an associated both-column acetabular fracture with entrapment of the external iliac vein in the fracture. This complication was not recognized until fracture manipulation during open reduction and fixation. This case report demonstrates that an acetabular fracture can have an associated vascular injury without any obvious clinical signs. This can be especially dangerous during percutaneous manipulation and fixation of these fractures as an obstruction or injury to the external iliac vein may occur and remain unrecognized. We feel that any surgeon involved in treating patients with acetabular or pelvic fractures should be aware of this potentially serious complication.

Superior gluteal artery in the extended iliofemoral approach

OBJECTIVE

To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis.

DESIGN

Prospective protocol, consecutive cases.

SETTING

A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors.

PATIENTS

Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters).

INTERVENTION

All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column.

MAIN OUTCOME MEASURE

Wound complications, abductor manual muscle testing, hip range of motion.

RESULTS

Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength.

CONCLUSIONS

No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.